CONFINED SPACE ENTRY PERMIT
Use this permit when entering a permit-required confined space, which is only valid for the duration of work being performed and for no more than 8 hours. Safe
Operating Procedures (SOPs) are required in addition to this permit. Post this permit at or near the entry point. An attendant is required outside the space and
must maintain communication with the entrant(s) and have a means to summon rescue services (e.g., 911). Review confined space assessments and the work to
be performed to determine the entry requirements.
General
Space to be Entered: Date & Time Issued:
Location of Space: Date & Time of Expiration:
Purpose of Entry: Department or Contractor:
Entrant(s):
Attendant(s):
Requirements
None Atmospheric Entrapment Engulfment/Suffocation
Assessment Reviewed: Actual or Potential Hazards:
Steam Condensate Other (Specify)
Special Requirements Yes N/A Special Equipment Yes N/A
Secure Area or Work Zone (e.g., barricading, fencing-off) Fire Extinguisher (not CO2)
Pumps / Lines Blanked, Blocked, Capped (i.e., LOTO) Special Lighting (e.g., explosion-proof)
Purging, Flushing, Venting of Utility Lines Portable Blower (i.e., forced-air ventilation)
Other Permits (e.g., Hot Work): (specify) Water Pumps
Other Special Requirements: (specify) Other Equipment: (specify)
Electrical Mechanical Hydraulic Pneumatic Chemical Thermal Steam Condensate
Energy Sources Isolated:
Other (specify)
Entrant Communication: Radio Cellular Phone Visual Verbal Fixed Telephone Other (specify)
Required Personal Protective Gloves Safety Glasses Goggles Face Shield Hardhat Ear Plugs/Ear Muffs Respirator
Equipment: Safety Shoes/Boots Long Sleeves/Pants Body Protection Other (specify)
Atmospheric Testing
Pre-Entry Time During Entry - Record Readings Every 2 Hours
Atmospheric Gases Permissible Limits Time (8-hour maximum)
(test in this order) (must be within limits) AM AM AM AM AM AM
PM PM PM PM PM PM
Oxygen (O2) 19.5% to 23.5% % % % % % %
Lower Explosive Limit (LEL) Under 10% % % % % % %
Carbon Monoxide (CO) Under 35 ppm ppm ppm ppm ppm ppm ppm
Hydrogen Sulfide (H2S) Under 10 ppm ppm ppm ppm ppm ppm ppm
Other: (specify) (specify)
Tester's Initials:
Monitoring Equipment Make and Model Serial Number Calibration Date Bump test Yes
passed prior
to use?
(required)
Rescue
Rescue Method Yes N/A Attendant Requirement Yes N/A
Non-Entry Retrieval Equipment (e.g., tripod, lifeline, hoist, harness) Trained in the Use of Non-Entry Equipment
Rescue Service On-Site (SCBAs, entry retrieval equipment) Has Means to Summon Rescue Services (required)
Rescue Communication: Radio Cellular Phone Visual Verbal Fixed Telephone Other (specify)
Northwestern Police Notified Prior to Entry: Evanston Campus (847) 491-3456 Chicago Campus (312) 503-3456
Authorization
I have reviewed the work authorized by this permit and the information contained herein. This permit is not valid unless all appropriate items are
completed. I certify that all actions and conditions necessary for safe entry have been performed.
Entry Supervisor: (print): (sign): (title):
Cancellation
Entry will be terminated and this permit will be cancelled when the entry operations covered by the permit have been completed or a condition that
is not allowed under the entry permit arises in or near the permit space. Re-entry into the confined space will not be allowed until a new
assessment is completed and a permit is issued.
This permit must be cancelled by the Entry Supervisor and submitted to Northwestern Environmental Health and Safety (EHS).
Permit Cancelled by: Date & Time:
Reason: Work Complete Rescue Unavailable Conditions Violate Permit New Hazards Other (Specify)
March 2025
